Massive Transfusion and

Massive Transfusion Protocols

Robert T. Russell, MD, MPH

November 2019

Pediatric Trauma Society

Massive Transfusion and

Massive Transfusion Protocols

No Disclosures

Objectives

• Review data associated with massive transfusion in adults and children

• Defining Massive Transfusion

• Predictors for activation

• Outcomes from utilization

• MTP creation

• Resources

• Monitoring response

• Use of simulation

Damage Control Resuscitation

Hemorrhage control

Permissive hypotension

Hemostatic resuscitation

The “Old” Approach

20 mL/kg isotonic crystalloid

Reassess

20 mL/kg isotonic crystalloid

Reassess

20 mL/kg isotonic crystalloidconsider 10-20 mL/kg packed red cells

Crystalloid Based“Resuscitation”

• Dilutional coagulopathy

• Excessive third spacing

• Abdominal compartment syndrome

• Pulmonary edema

• Cerebral edema

• Ileus

• Hypothermia

• Acidosis (hyperchloremia)

• 200 pediatric trauma patients (2013-2015)

• Avg crystalloid volume first 24 hours 41 ml/kg/day; 48 hr 28ml/kg/day

• Patients who received > 60 ml/kg/day crystalloid in 1st 24 hrs had: • Increased vent, ICU days, hospital days, time to regular diet resumption

• Appropriate adjustment for age, weight, GCS, ISS

• 2.5% transfused with PRBC, 1.5% with platelets/FFP

JPS 53 (2018) 2202-2208.

Massive Transfusion Protocols

• Provide large amounts of blood products to critically injured patients in an immediate and sustained manner

• Predefined ratios of platelets, plasma and RBCs

Defining Massive Transfusion?

• Define pediatric massive transfusion = 40 ml/kg/24 hours total blood products

Defining Massive Transfusion in Civilian Pediatric Trauma

Retrospective review, 2014-2015

ACS TQIP

Age < 18 years, ISS > 25

Excluding burns, non-survivable injury

JPS 54 (2019) 975-979.

Massive Transfusion in

Non-TBI

• Mortality

• 37 ml/kg/4-hours

• AUC: 0.79

• OR 4.24; 95% CI 1.96-9.16; p<0.01

• Hemorrhage control procedure < 24 hours

• 37 ml/kg/4-hours

• AUC: 0.76

• OR 8.60; 95% CI 4.25-17.42; p<0.01

JPS 54 (2019) 975-979.

When should we activate an MTP?

• ABC Score

• Penetrating mechanism (0=no, 1=yes)

• ED SBP ≤ 90 (0=no, 1=yes)

• ED HR ≥ 120 (0=no, 1=yes)

• Positive FAST (0=no, 1=yes)

Predicted massive transfusion correctly 85% of the time75% sensitivity, 86% specificity

• ABCD Score

• Penetrating mechanism (0=no, 1=yes)

• Positive FAST (0=no, 1=yes)

• SIPA (Shock Index, Pediatric Adjusted—max HR/Min SBP)

• Lactate (0=<-8.8, 1=>-8.8)

• Base Deficit (0= <3.5, 1=>3.5)

JPS In Press.

Predicted massive transfusion correctly 77% of the time

MTP in Adults

• Single center, retrospective, 2004-2006

• All TEP (MTP) activations (N=94)

• Comparison group (2004-2006) (N=117)

• No difference in age, gender, ISS

• 74% reduction in mortality in TEP/MTP group

• Pragmatic Randomized Optimal Platelet and Plasma Ratios

• 1:1:1 = 338; 1:1:2 = 342

• No difference in 24h or 30d mortality

• 1:1:1 vs. 1:1:2

• Hemostasis (86.1 vs 78.1%)

• Less death by exsanguination (9.2 vs 14.6%)Month 2016

Massive Transfusion in Children

• Single center, retrospective, 2005-2014

• ED presentation, RBC administered < 24 hours

• Pre (125) vs post (115) MTP implementation

• MT: > 40 ml/kg RBC or >80 mg/kg total blood products in 24-hours

• MT were more severely injured and coagulopathic

• No difference in mortality

• ↓ Time to plasma and platelet administration

• ↑ Plasma and PLT:RBC ratios

Month 2016

• DOD Trauma Registry retrospective review

• 364 children

• 2001-2013; age < 18; excluded TBI

• MTP> 40 ml/kg/24-hour total blood products

Month 2016

• Five ATOMAC Level 1 PTCs

• 110 children

• Two PRBC, 20 ml/kg of PRBC, or MTP

• Grouped by transfusion ratio in first 24 hours

• Survival benefit for 1:1 pRBC:FFP over higher ratios

• Holds true independent of age

Month 2016

JPS 54 (2019) 345-349.

A High Ratio of Plasma:RBC Improves Survival in Massively Transfused Injured Children

• Retrospective review

• ACS TQIP

• 1/2015 to 12/2016

• Plasma/Platelet:RBC• Low <1:2

• Medium >1:2 - < 1:1

• High >1:1

JSR 2019 (233) 213-220.

JSR 2019 (233) 213-220.

Data Conclusions

• Tough question to study in retrospective fashion, heterogeneity of populations, rarity of event

• Those receiving massive transfusion and increased product are more severely injured

• Older children get more plasma and have higher plasma:PRBC ratios

• Children that get more higher plasma:pRBCratios may have improved survival, fewer vent days, but similar ICU LOS

• Ratio of platelets:pRBCs did not seem to affect mortality, vent days or LOS

A Survey of Pediatric Massive Transfusion Protocol Polices

• 46 Children’s hospitals

• Physician discretion was the most common activation criteria (89%)

• Most sites targeted equal ratios of plasma: PRBCs; 15% of respondents used antifibrinolytics

• Wide variation in MTPs among pediatric hospitals

• Activation criteria and products administered

Transfusion Med. 2016 Feb; 26(1): 49-56.

Development of MTP at your hospital

• Consider your local environment, resources, data to inform the process

• Trauma Program

• High Risk Surgeries—trauma, craniofacial, spinal fusion

• Blood Bank—evaluate potential availability of products, supply chain

• Utilize Pediatric Trauma Society Resources

https://pediatrictraumasociety.org/resources/clinical-resources.cgi

Who should be engaged in the process?

Surgery/Trauma

Emergency Medicine/NICU/PICU

Blood Bank

Anesthesia

Nursing

Transport Services

Communications

Conclusions

Highlighted data surrounding

• Pediatric MTP definition

• MTP activation triggers

• Outcomes of MTP in children

Creation and implementation of MTP